Cardiac magnetic resonance–guided pacemapping for ventricular tachycardia substrate ablation in sinus rhythm in a patient with nonischemic cardiomyopathy

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Nonischemic cardiomyopathy with midmyocardial basal septal scar and repetitive monomorphic ventricular tachycardia (n=1). Intervention: LGE-CMR pixel signal intensity map-guided pacemapping and radiofrequency catheter ablation of heterogeneous tissue channel entrances in sinus rhythm. Primary outcome: Ventricular tachycardia noninducibility and freedom from VT recurrence at 9 months.

Q: What does this research mean for the field?

LGE-CMR-guided pacemapping and ablation targeting heterogeneous tissue channel entrances achieves acute VT noninducibility and prevents recurrence in nonischemic cardiomyopathy without requiring electroanatomical mapping. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Alfredo Chauca; David Soto‐Iglesias; Diego Penela; Antonio Berruezo

doi:10.1016/j.hrcr.2021.10.001

October 13, 2021HeartRhythm Case ReportsOpen Access

Cardiac magnetic resonance–guided pacemapping for ventricular tachycardia substrate ablation in sinus rhythm in a patient with nonischemic cardiomyopathy

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Key result

LGE-CMR-guided pacemapping and channel ablation achieves noninducibility with 0 VT recurrences at 9 months.

n=1

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Key Points

To describe a substrate ablation approach guided by late gadolinium enhancement cardiac magnetic resonance imaging and sinus rhythm pacemapping for ventricular tachycardia in nonischemic cardiomyopathy without electroanatomical mapping.
Reconstructed preprocedural late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) images using ADAS 3D software to generate pixel signal intensity (PSI) maps and identify heterogeneous tissue channels (HTCs) within a basal septal midmyocardial scar.
Merged PSI maps with multidetector CT into the CARTO system via a fast aortic root anatomical map in a 78-year-old male with nonischemic cardiomyopathy and recurrent monomorphic VT.
Performed pacemapping during sinus rhythm at HTC entrances (4 mA output, 2 ms pulse duration) and delivered radiofrequency ablation (40 W, 45ºC) while sparing conduction tissue displaying His potentials.
Pacemapping at HTC entrances reproduced the morphology of all 3 induced nontolerated VTs (cycle lengths of 300 ms, 335 ms, and 323 ms).
Delivered 6 radiofrequency ablations to 3 of 4 HTC entrances (mean ablation index 460, total ablation time 318 seconds), withholding energy delivery at the fourth entrance due to an identified His potential.
Abolished all VT inducibility with a total procedure time of 90 minutes and fluoroscopy time of 8 minutes, with no VT recurrence observed after 9 months of follow-up without amiodarone.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient aged 78 years with nonischemic cardiomyopathy, moderate LV systolic dysfunction, and amiodarone-refractory repetitive monomorphic VT, followed for 9 months.

I

Intervention

Preprocedural LGE-CMR and MDCT image integration (ADAS 3D LV software and CARTO system) with pixel signal intensity (PSI) map-guided pacemapping (4 mA output, 2 ms pulse duration) in sinus rhythm and radiofrequency catheter ablation (ThermoCool SmartTouch; 6 applications at 3 of 4 heterogeneous tissue channel entrances, 40 W, 45°C, 30 mL/min, mean 460 ablation index, total 318 seconds ablation time) without electroanatomical mapping.

O

Outcome

Acute noninducibility of ventricular tachycardia via aggressive programmed stimulation from the right ventricular apex and freedom from VT recurrence at 9 months follow-up after amiodarone withdrawal.hard clinical

LGE-CMR pixel signal intensity maps combined with pacemapping in sinus rhythm can successfully guide substrate ablation of hemodynamically nontolerated VT in nonischemic cardiomyopathy with midseptal scar without requiring time-consuming electroanatomical mapping.

Limitations

Lack of activation map or entrainment maneuvers owing to hemodynamic instability of induced VTs does not permit assurance that RF was delivered exactly at the HTC entrance instead of its neighboring area.
Lack of electroanatomical mapping (EAM) prevents performance of a direct comparison between uni-bipolar voltage and LGE-CMR information.
Lack of activation map or entrainment maneuvers owing to hemodynamic instability of induced VTs does not permit assurance that RF was delivered exactly at the HTC entrance instead of at its neighboring area
Lack of electroanatomical mapping prevents performance of a direct comparison between uni-bipolar voltage and LGE-CMR information

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Implication

May facilitate efficient VT ablation without electroanatomical mapping in nonischemic cardiomyopathy; leaves open prospective validation before wider adoption.

Abstract

Substrate mapping–guided ablation is a recommended therapeutic option in patients with recurrent episodes of scar-related ventricular tachycardia (VT).1 Color-coded pixel signal intensity (PSI) maps obtained from preprocedural late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging can be used for identification and characterization of arrhythmic substrate.2 PSI maps permit visualizing the border zone areas distribution inside the scar as corridors of viable tissue connecting the healthy myocardium, defined as heterogeneous tissue channels (HTCs), that correlate with the conducting channels on the electroanatomical mapping (EAM).

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Cite This Study

Chauca et al. (2021) conducted a case report in Nonischemic cardiomyopathy with midmyocardial basal septal scar and repetitive monomorphic ventricular tachycardia (n=1). LGE-CMR pixel signal intensity map-guided pacemapping and radiofrequency catheter ablation of heterogeneous tissue channel entrances in sinus rhythm was evaluated on Ventricular tachycardia noninducibility and freedom from VT recurrence at 9 months. LGE-CMR-guided pacemapping and ablation at 3 heterogeneous tissue channel entrances achieved 94%-96% VT morphology concordance, acute noninducibility of 3 VTs, and 0 VT recurrences at 9 months.

synapsesocial.com/papers/6a857a4ad06b31cc19d0c163 https://doi.org/10.1016/j.hrcr.2021.10.001

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Cardiac magnetic resonance–guided pacemapping for ventricular tachycardia substrate ablation in sinus rhythm in a patient with nonischemic cardiomyopathy

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac magnetic resonance–guided pacemapping for ventricular tachycardia substrate ablation in sinus rhythm in a patient with nonischemic cardiomyopathy

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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